TELE-SERVICES SUMMARY

There are many new developments related to telehealth services and some new issues directed related to the COVID-19 crisis. Let’s review what was in place before the new CMS decision related to our current health care crisis then we can summarize what recently changed.

This service is used to “check-up” on a patient where you are monitoring their status, symptoms or their response to treatment. The key components of this service are:

• Request must be initiated by the patient.
• To be HIPAA compliant, you must have prior authorization from the patient. If you are interested in making this a part of your operations, it would be advisable to add a statement authorizing this action to your other documents you ask the patient to sign. An example of consent language could be:
• “I authorize Practice Name to contact me by telephone or other media devices for communications needed to monitor my progress to recommended care”
• This service only applies to established patients.
• You cannot bill this service if you have seen the patient within 7 days before the communication or the communication results in an office visit within 24 hours of the communication.
• Standard co-insurance, copays and deductibles apply
• This service is recognized by CMS for Medicare and Medicaid recipients. Other payers may or may not recognize the service.
• All aspects of the encounter should be properly documented in the patient’s medical record. Recording the encounter is not required but advisable if possible.

The service is billed using the following codes

• G2012 This is for communication by telephone, typically a 5-10 minute discussion with the patient.
• G2010 This is for communication using video or image systems

These are telephone consultations that are initiated by the attending physician to follow up on a patient’s status. The key components of this service are:

• The service is typically initiated by the attending physician
• You cannot bill this service if you have seen the patient within 7 days before the communication or the communication results in an office visit within 24 hours of the communication
• This service cannot be used to monitor post-operative status of patients as that is already included in the global fee payment
• This service is not normally covered by Medicare and Medicaid and not routinely covered by most payers – however, Effective April 17 (with fee adjustments retroactive to March 1), CMS will allow reimbursement for these codes during the COVID-19 crisis.  The reimbursement for the codes is also increased.

The service is billed using the following codes:

• 99441 Telephone encounter lasting 5-10 minutes
• 99442 Telephone encounter lasting 11-20 minutes
• 99443 Telephone encounter lasting 21-30 minutes

This is a teleservice that occurs mainly using the practice’s electronic medical record portal. It would also involve the use of video or image review and communication with the patient. The key components of this service are as follows.

• The communication must be initiated by the patient.
• This service applies only to established patients.
• You cannot bill this service if you have seen the patient within 7 days before the communication or the communication results in an office visit within 24 hours of the communication.
• Co-insurance, copays and deductibles apply
• All aspects of the encounter should be documented in the patient’s electronic medical record

The service is billed using the following codes:

• 99421 Online digital evaluation typically lasting 5-10 minutes
• 99422 Online digital evaluation typically lasting 11-10 minutes
• 99423 Online evaluation typically lasting greater than 21 minutes

This is a remote patient evaluation using real time, interactive, two-way audio/visual communication systems. The key elements of these services include:

• Use of these services under Medicare is restricted to counties outside the Metropolitan Statistical Area (MSA) or inside a Health Professional Shortage Area (HPSA).
• Usually does not involve provision of services to a patient at home
• Generally used for established patients but new patient encounters not prohibited
• The service is billed using the regular evaluation and management codes. It is not payable for ophthalmologic codes.
• Use of the -95 modifier is recommended but unclear if this is will be a requirement for claims submissions
• The place of service code for these services is – 11 -telehealth (clarified by CMS on March 31)

The criteria for selecting the code level are exactly the same as for in-office services. There is certainly a limit on the number of examination elements that can be conducted using remote technology which can be a limiting factor in code level determination. Time as the single determining factor or code level selection can be used and should be documented properly.

On March 17, 2020, CMS announced modifications to the tele-service system. The modifications are to allow expanded use of these services in light of the current COVID-19 crisis. CMS actions did the following:

• Allowed providers to forgo collection of applicable copays and deductibles for these services. Note that is at the provider’s discretion – you can still collect copays and deductibles if you wish. It is unclear at this time how CMS will adjudicate the claims related to waived or non-waived encounters.
• Allows provision of services to new patients (in addition to established patients)
• HIPAA privacy rules were relaxed for tele-services. It is stated that no investigations or audit of services will be conducted – but only related to these telehealth services. HIPAA did not go away.
• Removed the restriction that telehealth services are only applicable outside of MSAs and inside HPSAs. They can be utilized anywhere during this until the crisis amendments are removed.
• Removed the restriction that telehealth services can not be provided at the patient’s home.
• Allowed Non-HIPAA compliant platforms for use in Telehealth during the COVID crisis as long as they are not public facing. Examples given include: Apple FaceTime, Facebook Messenger video chat, Google Hangouts video, Whatsapp video chat, Skype

The relaxed rules did not state investigations for improper coding and HIPAA compliance would be eliminated outside of the telehealth services.

CMS actions are not binding on other health care payers. Each payer is likely to make their own rulings regarding any action related to telehealth services during the COVID-19 crisis. Individual states also may have regulations regarding telehealth services that could affect optometric provision of these services outside of the CMS system. States are likely to also implement emergency rulings to increase access to telehealth services.